It's TIME—the theme of World Tuberculosis (TB) Day observed on March 24, 2019 sounded a clarion call to action for putting an end to the TB epidemic worldwide. Since the discovery of the Mycobacterium tuberculosis, 137 years ago, we continue to contend with issues of high incidence, late detection, poor treatment adherence, social stigma, and discrimination for a disease that is both preventable and curable.

Indeed, it is time to deeply examine the social and financial determinants of outcomes of TB treatment in order to formulate more nuanced solutions to those already suffering from this disease. In a tribal village of rural Rajasthan, the story of Ramu, a frail looking man in his late 30s, underscores a neglected piece of the puzzle that needs urgent attention. Ramu Gameti (name changed) used to work in the construction sector in Udaipur, earning up to 300 rupees a day and supporting his family of three. Ramu first noticed the symptoms of tuberculosis over 2 years ago. After several misdiagnoses and expensive treatments, Ramu became physically incapable of working for long hours. When he discovered that he was, in fact, suffering from TB, he chose to avail treatment at a private hospital more than 50 km away from his village for fear of social ostracization in his community. In order to meet his family's daily needs, Ramu kept working intermittently whenever possible, often missing his treatment doses. For over a year, Ramu was unable to go to work because of his deteriorating physical condition. Although informal borrowings helped support his household expenses for a few months, eventually, his 12-year-old son was compelled to drop out of school and migrated to Rajkot for work.

Like Ramu, a large proportion of diagnosed workers fail to complete the entire course of treatment and are compelled to engage in manual labor without having fully recovered. TB is a leading public health concern in India. India accounted for nearly 27% of the deaths caused by TB globally, with successful treatment outcomes much below the global average of 81% (World Health Organization 2018).[1] The extremely low levels of treatment adherence are a cause for concern. TB disproportionately affects informal workers like Ramu, particularly migrants who work in cramped units and live in squalid congested spaces in the cities. Migration and conditions of work and employment have been widely recognized as social determinants of health (STOP TB Partnership 2016; IOM, WHO 2014).[2],[3] However, a missing narrative in the poor adherence to TB treatment in India is in fact, financial.

Evidence from Shram Sarathi's1 work provides a financial perspective on poor treatment adherence among TB affected migrants (Kulkarni and Padmanabhan 2019).[4] Delay in detection and diagnosis affects the family's financial well-being in several ways. The gradual declining capacity to work results in significant income loss, while misdiagnosis or private treatments can result in catastrophic health care costs for the affected worker. It was found that workers spent an average of 2000–3000 rupees per week seeking private treatment for TB. Further, just before a proper diagnosis, workers had average informal debt levels of 15,000–20,000 rupees. This increased at least two-fold during the treatment period. During the first few months of treatment, workers would be too physically weak and unable to work. Thus, they would exhaust all of their savings, often resort to distress sale of assets such as livestock and jewelry, and even borrow from informal sources. In the fourth or fifth month of treatment there would be some improvement in physical health. This combined with their precarious financial situation would prompt such workers to migrate yet again. In the absence of adequate rest, nutrition, and physically demanding work, most of such workers would default on treatment, thereby increasing the risk of relapse and contagion. An interesting observation also was that workers would not significantly alter their spending patterns as a result of a TB diagnosis. Social spending in particular would be maintained in order to avoid any speculation around their health in the community. Invariably, migrants who were away from their villages for longer duration or workers who migrated longer distances were financially most vulnerable and more prone to poor treatment adherence.

Given these trends, it is time therefore for health care professionals to engage more deeply and meaningfully with the financial behaviors of TB affected households. Such financial behavior is not limited to just the cost of health care or nutrition but also includes other spending patterns and debt levels in the household. If we are able to successfully identify who is most vulnerable; when are they most vulnerable during the treatment period; and how do they prioritize expenses and manage resources during treatment, then it becomes possible to effectively combine strong public health interventions with financial support and rehabilitation. Financial instruments that are well aligned with the financial behaviors of TB affected workers during the treatment period can thus help us significantly improve treatment adherence rates and well-being. It is time therefore for more collaborative models of public health and financial services to put an end to the TB epidemic worldwide.